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'iE ISiiUaOS ÍEOOS V. SI U3S UnjSB>l 0 „ ,-. \ J. : ' : ľ : ■ " • siuauižasaSJEi iinsajEsv'JOodaqiJOisaaiAjasaAiiaajiau! pi 'UJnig|aa:':dJ3AAluv 'pajuiofsip puE ljdü am joj. 9Jed mieaii ôA.isusdxa ui paijnsaj á|9§j .'aupipawlEDidojijo.aimiisuraqi. babu.aaEp.oasapi|odqaiEaqiEUopujaiuimoqsaquDsap>|oc lBjaq3JB3sajES!3d3BdaaaJJ3j|Ooqsiqi'saujunoaaujoai j aqjjojoj3ajtp-03puEjajnjoa| -aippiuj puB -moi u.ojhojo Aj3Ai|9p ai|i uojDHdujj joíhlu b pB I i. jO!U3c.su32un3JJ3!d-UEa| 3AEqsapB33poMjjSEd3qjjos3p!|odp!EpuBqj|Baq|Euo!JBUJaju Contents CAMBRIDGE UNIVERSITY PRESS Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, Sao Paulo, Delhi, Dubai, Tokyo Cambridge University Press The Edinburgh Building, Cambridge CB2 8RU, UK Published in the United States of America by Cambridge University Press, New York www.cambridge.org Information on this title: www.cambridge.org/9780521174268 © Institute of Tropical Medicine 2010 This publication is in copyright. Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First published 2010 Printed in the United Kingdom at the University Press, Cambridge A catalog record for this publication is available from the British Library Library of Congress Cataloging in Publication Data International health and aid policies: the need for alternatives / [edited by] Jean-Pierre Unger... [et al.]. p. cm. Includes bibliographical references and index. ISBN 978-0-521-17426-8 (pbk.) 1. Public health-International cooperation. 2. World health. 3. Poor-Medical care. 4. Medically underserved areas. 5. Medical care-Developing countries. I. Unger, Jean-Pierre, 1954-11. Title. RA441.I565 2010 362.1-dc22 2010021038 ISBN978-0-521-17426-8 Paperback Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Every effort has been made in preparing this book to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved. Nevertheless, the authors, editors and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use. Preface page vii Biographies ix Notices xv Acknowledgements xvii List of abbreviations xix Revievt>s xxiii introduction: Overview and purpose xxv Origins Content Relevance Definitions Section 1: Paradigms of international policies 1 Donor led policies: analysis of an underlying doctrine 3 The Achilles heel of international health policies in low- and middle-income countries 16 Section 2: The failure of the aid paradigm: poor disease control in developing countries 35 Why do disease-control programmes require patients in health services to succeed in delivering? The case of malaria control in Mali 37 How do disease-control programmes damage health care delivery in developing countries? 48 Privatization (PPM-DOTS) strategy for tuberculosis control: how evidence-based is it? 57 10 Section 3: Impact of international health policies on access to health in middle-income countries: some experiences from Latin America 67 Costa Rica: achievements of a heterodox health policy 69 Colombia: in vivo test of health sector privatization in the developing world 83 Chile's neoliberal health reform: an assessment and a critique 97 Section 4: Determinants and implications of new liberal health policies: the case of India, China and Lebanon 107 Political and economic determinants of health care systems: the case of India 109 An economic insight into health care provision in six Chinese counties: equity in crisis? 123 Health care financing and delivery in the context of conflict and crisis: the case of Lebanon 138 Section 5: Principles for alternative, publicly oriented health care policies, planning, management and delivery 153 12 Paradigm shifts in the health sector: mission and methods 155 Part 1: The need to alter health systems' missions to deliver comprehensive care Part 2: The need for a methodological shift to determine priorities in health policies 13 Principles for an alternative, social and democratic health policy 164 14 Quality standards for health care delivery and management in publicly oriented health services 176 15 Principles of publicly oriented health planning 184 16 A code of good practice for the management of disease-control programmes 195 Section 6: A public health, strategic toolkit to implement these alternatives 199 17 Person-centred care: a key to strengthening health care and systems in low- and middle-income countries 201 18 Improving access 210 Part 1: Access to curative care in first-line health services: an experience in Ecuador Part 2: Improving access to drugs in publicly oriented services: an experience in Senegal 19 Improving clinical decision making 225 Part 1: Non-managed care techniques to improve clinical practice Part 2: Interface flow process audit. The patient's career as tracer of quality of care and system: an experience from Belgium 20 Reorienting academic missions: how can public health departments and public health teaching in particular best support access to good quality comprehensive health care? 240 Conclusions 247 Glossary 255 Index 257 'This book explores health policies through examining patterns of commercialization that have underpinned the vast majority of these policies in different regions of the world, at the same time providing the reader with both concepts in public health and techniques to develop health services with a social mission. The chapters in the book include case studies and an extensive review of the literature. We began this task with one main purpose: to explore the extent to which donors and international agencies have, over the past two decades, shared the same underlying motivation: that is to primarily commercialize the health sector of low-income countries (LIC) and middle-income countries (MIC), despite the stated aim of improving access to health care and addressing issues of poverty and exclusion. In this book, we provide evidence showing the contradictions between access to care and strengthening health systems on the one hand and increased commercialization on the other. The ideas and evidence presented in this book thus call for an exploration of the contradictions of commercialized health care delivery under the guise of maintaining public provision. The book challenges the discourse and status quo among national bodies, in global policy circles, among donors and northern governments. It argues for - the creation of health care services that have a social rather than a commercial motivation, and - delivery of publicly oriented health care based on (professionally defined) needs' and on the (population) 'demand' to access quality, polyvalent health care, rather than on health interventions efficiency only. Authors Jean-Pierre Unger (MD 1979 and PhD 1991, Free University of Brussels; DTM&H 1980, ITM Antwerp; MPH 1983, Harvard School of Public Health) is senior lecturer at the Institute of Tropical Medicine, Antwerp. He started his career in 1981, as a doctor, in the ITM Kasongo project, Congo, then gained experience in health systems and academic development mainly in Africa (in the 1980s and early 1990s) and in Latin America thereafter. He researched strategies to develop publicly oriented health care services (in Africa, Latin America, Asia, Middle East, and Europe), and, since 2000, studies international health policies. Pierre De Paepe (MD 1977, Antwerp; MPH 1985, Buenos Aires; certificate in health economics 2005, York) spent 25 years in Latin America (Haiti, Peru, Argentina and Ecuador) and has worked at the ITM since 2003 at the Public Policy and Management Unit. His professional experience focused on the implementation of primary health care programmes, health systems analysis, the documentation of country case studies of Latin America, health systems funding, and financing. He is currently studying Colombian and Brazilian health policies. Kasturi Sen (Dip Soc. Pol, PhD) is a social scientist who has worked on issues of public health and development for the past 25 years. She helped set up a network of seven countries to monitor the public health implications of health reforms in the late 1990s in India and also worked with statisticians, economists and epidemiologists to collect one of the largest data sets on household level impact of changes in the organization of health services in three states of India, on safety nets, on quality and on access to care. Kasturi has taught in public health departments at London (1991-1995), Cambridge (1996-2004) and at Oxford (2005-2008) where she helped establish a course on public health and development. She is working on a collaborative project on global health policies at ITM. Werner Soors was born in 1955 in Antwerp (MD 1986, University of Antwerp, DTM&H) and worked in Nicaragua up until 2003, with a strong focus on public health care and community participation. Back in Antwerp, he attained his MPH and has been with ITM since 2004. He works in ITM's Department of Public Health on health systems and reform analysis (Public Policy and Management Unit) and on social protection in health (Health Policy and Financing Unit). Contributors Luis Abad MD (State University of Cuenca, Ecuador), MPH (National North East University, Argentina), has been district medical officer for the Azogues Health Area, Cafiar Province in southern Ecuador, since 1992. He has been a public health advisor of the 'Primary Health Care - APS project' by the Belgian Technical Cooperation Organisation in Ecuador (1994-2003). He also lectures on occasion in public health and health systems organization in the Masters in Public Health Course of the Pontificia Universidad Catolica del Ecuador, PUCE, Ecuador. Oscar Arteaga MD, MSc, DrPH. Health Policy and Management Unit> School of Public Health, Faculty of Medicine, University of Chile. Academic Director of University of Chiles Master in Public Health Programme. Lennart Bogg MSc, PhD economist, BA (Sinology), MScBA (Uppsala University). Served with UNICEF in Burma and in China (1982-1988); from 1988 with Swedish International Development Cooperation Agency (SIDA), Stockholm, first as Financial Controller in the Finance Department and later as Economist (Health Policy) with the Department of Eastern Europe and Central Asia, with UNRWA as Finance Director (Gaza), and with the World Bank Baltic Regional Office as social sector economist. Since 2004 Senior Researcher, Division of Global Health (HCAR), Karolinska Institute (research addressing rural health insurance in Asia, barriers to maternal health in China), and Senior Lecturer (Financial Management), School of Sustainable Development of Society and Technology (HST), Malardalen University, Sweden. Rene Buitron MD, MPH, MSc, physician and epidemiologist by training, has directed the Institute of Public Health, Pontiiicia Universidad Catolica del Ecuador, Quito, where he is now Professor of pre- and postgraduate courses and Vice Dean of the medical faculty. Daniel Burdet MD (Free University of Brussels 1977), general practitioner working in a multidisciplinary primary care team (Maison Medicale Forest), is training supervisor in general practice, quality coordinator, health care manager and a member of the Health Promotion and Quality workgroup (EPSQ) in the Federation des Maisons Medicales. Bart Criel MD, DTM&H, MSc, PhD, senior lecturer at the Department of Public Health of the Institute of Tropical Medicine (ITM) in Antwerp, Belgium. He worked as medical officer in rural Democratic Republic of Congo (1983-1990) and joined the ITM in 1990. He has extensive experience in health systems research with a special focus on district health systems and on arrangements for social protection in health in sub-Saharan countries and in the Indian sub-continent. Umberto d'Alessandro MD (Pisa 1982), MSc (London 1990) and PhD (London 1996) is Professor of parasitology and head of the epidemiological parasitology unit (Institute of Tropical Medicine, Antwerp). He has extensively studied malaria control and clinical trials in malariology. Tony De Groote MD, DTM&H, MPH, worked mainly in sub-Saharan Africa and Latin America. He is Assistant Professor at St. Georges University in Grenada. Paul De Munck MD, MPH, DTM&H, general practitioner, has 14 years' experience in family and community medicine in a Brussels multidisciplinary, self-managed primary health care centre. Since 1997 he has worked as a public health doctor to support health systems in sub-Saharan Africa. Moussa Diao is a retired nurse (Ecole Nationale des Infirmiers d'Etat, Dakar). He has had extensive experience in the field of primary health care and has been supervisor of the primary health care Kolda district in Senegal during the 1990s. Dong Hengjin BA in Public Health (1978-1983, Shanghai Medical University), MSc (in Health Statistics and Social Medicine 1983-1986), MA in Health Management, Planning and Policy (1990-1991, Nuffield Institute for Health, Leeds University), PhD (Karolinska Institute, area of Health Services Research). Professor and director of the Department of Hospital Management, vice-director of Health Technology Assessment (HTA) and Research Centre, Dean Assistant of School of Public Health at Shanghai Medical University (SMU) (1997-2000). Senior research fellow in Health Economics Research Group, Brunei University, UK (2004-2006) and senior lecturer at Heidelberg University (2000-2004). Currently leader of the Junior Group of International Health Economics and Technology Assessment at Heidelberg University, Germany. Sylvie Dugas MD, MPH, has experience in health services organization in Zimbabwe and Guinea and was Research Assistant at the Department of Public Health (Institute of Tropical Medicine, Antwerp). She currently works for the Ministere de la sante, de la famille et des personnes handicapees in France. Patricia Ghilbert RN, MCommH, MPH is a nurse specialized in public health. She has been a research assistant at the Institute of Tropical Medicine, Antwerp, and is currently working for the Federal Service of Health, Food Chain Safety and Environment, Directorate-General for the Organization of Health Care Establishments, Belgium. Andrew Green BA, MA, PhD, is Professor of International Health Planning at Leeds University, UK, and until recently, was head of its Nuffield Centre for International Health and Development. He teaches health policy, planning, and economics on undergraduate and postgraduate courses both at Leeds and as a guest lecturer in other institutions. His interest, research and publications focus on health planning, health policy processes, and the role of NGOs in health. He has held positions in Western and Southern Africa and the UK NHS as well as having conducted research and short-term consultancy in other parts of Africa, Asia, South America and the Caribbean. Pierre Leemans has been working as a general practitioner for more than 25 years. He has been practical trainer at the Free University of Brussels since 1991 and has responsibilities in the local GPs' organization (Brussels Region). Bruno Marchal MD, DTM&H, MPH, PhD, worked as district hospital director in Kenya between 1993 and 1999 and is currently a research fellow at the Department of Public Health, Institute of Tropical Medicine, Antwerp. His current research focuses on the role of (health workforce) management on hospital performance and evaluation of complex interventions in health care. Amadou Mbaye MD (Dakar University), MPH (ITM, Antwerp) is currently attached as a health specialist to the Union Economique et Monetaire Ouest Africaine (UEMOA). Imrana Qadeer is a J. P. Naik senior fellow at the Centre for Women's Development Studies at present and was Professor at the Centre of Social Medicine and Community Health (Jawaharlal Nehru University, New Delhi) that she joined after working at the AIIMS, Department of Paediatrics until 1971. She served as a member of the Review Committee for the National Rural Health Mission, Population Commission and several health and nutritional planning sub-groups in the Planning Commission of India. Current areas of research include the organization of health services in India, political economy of health, women's health, epidemiology, and interdisciplinary research methodology. She also continues to work with people's organizations working for health of the marginalized. Edgar W. Rojas Gonzalez MD (1988), MPH (1996), born in Azogues, Ecuador, was with the Ministry of Health from 1988 to 1997 as a clinician, and director of several services. Since 1999 he has been Professor on the MPH program and at the Nursing Faculty of the Pontificia Universidad Catolica del Ecuador. He has also worked as a national and international advisor and consultant in public health. He is currently Director of Nutrition in Ecuador's National Program 'Alimentate Ecuador' for the Ministry of Economic and Social Inclusion. Abla Mehio Sibai is Professor at the Department of Epidemiology and Population Health at the American University of Beirut, Lebanon. She has been involved in a number of major international research projects on population health and was scientific coordinator of the multi-centre EC-funded research on the impact of conflict on population health in Lebanon (1996-2000), the National Burden of Disease Study (2003), and more recently the NCD Risk Factors study in Lebanon. She is currently on several advisory committees, national, regional and international, to support the establishment of a database for reporting of morbidity and for policy formulation for the elderly population of Lebanon. She is a founder member and director of the Centre for Studies on Ageing in Lebanon. Giorgio Solimano, physician by training, is director of the School of Public Health, University of Chile, Santiago, and professor of public health. He has been professor associate and then professor from 1988 to 2006 at the School of Public Health, Health Sciences Faculty, Columbia University, New York. He has written numerous books and articles on public health and nutrition. Jacques Unger MD 1973, PhD 1983. Head of the Thyroid Unit Academic Hospital 1987-1994, Head of the Internal Medicine Department Cesar de Paepe 1994-1997, Moliere Hospital Brussels 1997-2001, Professor of Endocrinology 1990-1994 and of Internal Medicine 1998-2001. Jean Van der Vennet, is a medical sociologist (Free University of Brussels), who has been working for many years on the Belgian health system. He joined ITM as a medical sociologist in 1991. From 1993 to 1997 he was a Technical Adviser to the Regional Health Services of the Department of Cochabamba, Bolivia, based at the University Mayor de San Simon. At ITM he is currently working on the development of Local Health Systems in Belgium and also teaching Public Health and is responsible for the ITM's Alumni network. He also provides support to Masters students at the School of Public Health in Lubumbashi, in the Democratic Republic of the Congo. Patrick Van Dessel was born in 1964 in Antwerp, MD 1991, Ghent, Belgium, DTM&H 1992, and MPH 1997, ITM Antwerp, worked for more than a decade in Africa (Malawi, Rwanda) and Latin America (Bolivia) with a main interest in integrated health system organization and primary health care. He has experience with epidemiology and health care accessibility in neglected urban areas in Belgium (2004-2008) and has been working with ITM s Public Policy and Management Unit since 2008. His current focus in Antwerp is on health system research, public institutional capacity building and teaching public health in a globalized context. research in public health at the Institute of Tropical Medicine in Antwerp, with a special emphasis on human resources for health in developing cotmtries. Ingrid Vargas Lorenzo BA Econ, MSc, PhD, is a health economist, researcher at the Health Policy Unit of the Consorci Hospitalari de Catalunya, Barcelona, Spain, with experience in health policy analysis, health financing, equity and IHN. Published PhD Thesis: 'Barriers and facilitators for continuity of IHN in Colombia.' Maria Luisa Vazquez MD, PhD, MSc, Public Health specialist, is currently Head of Research of the Health Policy Research Unit of the Consorci Hospitalari de Catalunya, Barcelona, Spain. She started her career as a researcher at the Institute of Tropical Hygiene and Public Health, University of Heidelberg, and then continued as a lecturer at the Liverpool School of Tropical Medicine (UK), before moving to Spain in 1998. During the past 25 years she has gained wide experience in health systems and policy research in Latin America and Spain. She has published many national and international articles. Her particular areas of interest include access to health care, integrated health care, health policy analysis, and care to migrant populations. Marie-Jeanne Wuidar sociologist (Free University of Brussels, 1972), MD 1980. From 1980 onwards she has worked as a general practitioner at the Marconi Medical Centre, Brussels. She also has experience in the organization of the primary health services, Yanbu, Saudi Arabia. Walter Zocchi, MD (Milan University, 1974), DTM&H (ITM, 1996), MPH (ITM Antwerp, 2002), has worked as a surgeon and a general practitioner in Italy, Mozambique, Algiers, Burkina Faso and Sierra Leone. Since 1996 Walter Zocchi has worked with several NGOs in Haiti, Somalia, Montenegro, Serbia, Bosnia, Zimbabwe, Eritrea, Ecuador, Afghanistan, and India. Monique Van Dormael PhD in Sociology, started her career studying primary care group practices in Belgium and Europe. Since 1987 she has been involved in teaching and This book comes at a time of a highly needed reform in the Global Health Governance and the nternational Health Aid Architecture. The attention to health has been enhanced in glo bal fora and health aid has tripled in the last decade. We all share responsibility and the chal-enge to address the highly fragmented health landscape. The EU is developing a new policy framework aimed at greater equity and coherence in the EU role in global health. The agreel global commitment to universal coverage rescuing the Alma Ata principles and applying the ^maples of partnership and ownership to health in development aid are clear opportunfties The reflections of this book will be a valuable reference for our debate and the enhanced EU role m the global health challenges. Juan Garay Public Health Physician Health Team coordinator DG Development European Commission ntroduction - overview and purpose Confident in the infinity of time, a certain conception of history discerns only the rhythm, faster or slower, at which men and times move along the path of progress. Walter Benjamin, 1915. La vie des etudiants. In: W. Benjamin, CEuvres I, Folio Essais, Editions Gallimard, 2000, p. 125. Plato was the first to discern between those who know without acting and those who act without knowing while in the past, action was divided in enterprise and achievement: the result was that the knowledge of action to accomplish and its implementation became two radically different concepts. H. Arendt. Condition de I'homme moderne. Calmann Levy Ed., Paris, 1983, p. 286. After 15 years of neoliberal international health policy, data from 26 sub-Saharan countries reveals that more than 50% of the poorest children receive no health care when sick (Marek et al., 2005). Data from 44 low- to middle-income countries (LMICs) suggest that the greater the participation of the private sector in primary health care (PHC), the higher the exclusion from treatment and care (Macintosh & Koivusalo, 2005) across sectors. This is a textbook about public health with a difference. Firstly, it addresses policies relating to the delivery of health care - while the study of public health has historically evolved around issues of disease control. This book makes a case for alternative policies that could shape the structure and provision of universally accessible, polyvalent, discretionary health care, rather than making it work through its commodification1 and the priorities of cost-effective interventions in public services. Secondly, the articles we have included are critical of the debates over the political and technical paradigms of such discussion, often predicated, in our view, on international political ties and commercial relationships. Thirdly, a strong current of thinking in the book is the view, often neglected, that policies have a direct impact on the motivation and practice of professionals in the health sector and that such professionals can, and should, contribute towards developing health services with a social mission whatever the national health policy might dictate. In other words, the book approaches many of the contradictions of current policies from the perspective of practice. It thus offers a combination of theory, evidence from four continents and practice interwoven with guidance directed at policy makers, researchers, doctors, and nurses on ways and means to achieve comprehensive health care (CHC) provision in order to strengthen health systems. Consequently, this is a textbook also on health services organization, designed to open avenues for reflection and action for the reader. Its targeted audience includes students, researchers, and practitioners of public health as well as health professionals with a practice in LMICs. Whilst hierarchy conveys a top-down flow of authority, information, and ideology, this book aims at providing health professionals with action perspectives to amend (inter)national health policies in an experience-based perspective, in order to encourage the development of publicly oriented health services under any circumstance, wherever the health practitioners may be posted and whatever might be the national health policy. The book thus offers the reader arguments 1 To turn into, or treat as, a commodity; make commercial.